10-24-2020 Septic Compliance - Laserfiche WebLink

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Propertyaddress: 3625 Jacobs Mill Rd Kurt.& Carol Schmidt Parcel ID: 3211823240013 State: M N zip code: _ 55.56 --- city: Orono ---- — Optional section: Sewage Tank Compliance Certification This form does not represent a complete system inspection report and only certifies sewage tank compliance status. Instructions: This section of the form may be completed and signed by a Designated Certified Individual (DCI) of a licensed SSTS Maintenance Business who personally conducts the necessary procedures to assess the compliance status of each sewage tank in the system. When this section of the form is signed by a qualified certified professional, it becomes necessary supporting documentafion to an Existing System Compliance Inspection Report: Compliance inspection form Existing aystem (wa-wwists4�31 bl. This form can be found on the MPCA website at h state mn uslwaterlssts-and mats technical-and-eomniiance-criteria. The information and certified statement on this form is required when existing septic tank compliance status is determined by an individual other than the SSTS Inspector that submits the inspection report. It represents a third party assessment of SSTS component compliance and is allowable under Minn. R. 7082.0700, subp. 4 Item (B) subitem (1). This form is valid for a period of three years beyond the signature date on this form unless a new evaluation is requested by the owner or owner's agent or is required according to local regulations. Additional Administrative Rule references for this activity can be found at Minn. R. 7082.0700, subp. 4 Items B, C, and D; 7083.0730 Item C. ® Certificate of sewage tank compliance Affirm all three statements: �[ The SSTS does not contain a seepage pit, cesspool, drywell, leaching pit, or other pit. it does not contain a e tank that to be watertight, but subsequently leaks beed low the designed operating depth. It does not represent an imminent safety threat by reason of unsecured, damaged or weak maintenance hole cover(s) or other unsafe condition. Company Information Company name, Albin's Septic-Pumpi 12 LLC Business license number: 3346__, ❑ Notice of sewage tank non-compliance Select all that apply: ❑ The SSTS has a seepage pit, cesspool, drywell, leaching pit, or other pit. El It has a sewage tank that was designed to be watertight, but subsequently leaks below the designed operating depth. 0 It presents a threat to public safety by reason of unsecured, damaged, or weak maintenance hole cover(s) or other unsafe condition. Designated Certified Individual (DCI) Information Print name: Peter Peterson Certification number: 9227 I personally conducted the work descrbed above as a Designated Ced&d Individual of a Minnesota-Jicensed SSTS Maintenance Business. I personally conducted the n ry pmcedur;es to assess the compliance status of each sewage tank in this SSTS: Designated Certified 10/24/2020 Individual's signature: _ _ _ Date (mmlddlyyyy): _ www.pca.state.mn.us • 651-2%-6300 wq-ww1sts4.38 • 1127117 800.657-3864 use your preferred relay service Available in attemative formats Page 3 of 3